Monday, March 31, 2014

The United States Senate just passed HR 4302, the Protecting Access to Medicare Act. If signed into law by President Obama, then this bill will delay ICD-10 and shift required implementation from October 1, 2014 to as early as October 1, 2015. The act also extends the “doc fix” for Medicare’s Sustainable Growth Rate (SGR) payments for a year.

The bill was rapidly introduced to the House of Representatives on Thursday, March 27th, for vote. After a voice vote passage, it moved to the Senate for today’s vote. Primary arguments cited for delaying the ICD-10 implementation included lack of readiness surrounding clinical documentation, vendor solutions, and systems testing.

We encourage you to keep calm and code on.

If you are ready for implementation, then we know this delay may be difficult; we will support you with both access extensions and refresher courses. If you need another year, then this change offers an opportunity to increase your readiness through proactive education, practice, and testing. The postponement allows improvement of anatomical knowledge, review and adjustment of documentation quality and clinician education, and adjustment of coding and billing procedures.

AAPC remains committed to serving you with the highest quality training and support to help you adapt to the ever-changing healthcare environment.www.aapc.com

Never let it be said that the implementation of ICD-10 has not been exciting.

ICD-10 is still a critical project that will continue to require our full attention. One of the areas of implementation that seems to create the most anxiety is translation. So let’s talk about it.

You’ve probably heard about the concept a hundred times and in several ways, such as mapping, crosswalking, translating, converting, etc. But what does it really mean? And what is the best verb to describe it? I offer, for your consideration, a breakdown of the verbs that are associated with the act of identifying the ICD-10 counterpart for a given ICD-9 code, or vice versa:

Mapping – Using a starting point (ICD-9 code) and plotting an end point (ICD-10 code).

Crosswalking – Identifying a code that is the equivalent of a starting code (ICD-9 or ICD-10).

Converting – Changing policies, processes, and systems from current ICD-9 logic to ICD-10 logic, including the codes themselves.

Translating – Using all methods available (including mapping, crosswalking, and converting, along with review of business requirements, clinical equivalence and appropriateness, and standard coding methodologies and guidelines) to identify the equivalent code or codes in ICD-10.

Many people use these terms interchangeably, but I am here to offer a little perspective, having done all of the above with my own two hands. These are not the same actions, but each can be a step in a much larger process that we all must embark upon if we are to implement ICD-10.

We can’t use just one technique and call it a day. Case in point: we have all heard of the general equivalence mappings, or GEMs, that were developed by the Centers for Medicare & Medicaid Services (CMS) and 3M and released for free to the public for use in the transition to ICD-10. These mappings are also the standard “crosswalk” as required by the Patient Protection and Affordable Care Act. But these mappings, of which only a small percentage could be considered an actual “crosswalk,” are only a starting point in a much larger process. Look at this statement found in the GEMs User’s Guide:

“There is no simple ‘crosswalk from I-9 to I-10’ in the GEM files. A mapping that forces a simple correspondence — each I-9 code mapped only once — from the smaller, less detailed I-9 to the larger, more detailed I-10 defeats the purpose of upgrading to I-10. It obscures the differences between the two code sets and eliminates any possibility of benefiting from the improvement in data quality that I-10 offers. Instead of a simple crosswalk, the GEM files attempt to organize those differences in a meaningful way, by linking a code to all valid alternatives in the other code set from which choices can be made depending on the use to which the code is put.”

A simple solution is not always the best solution, and the translation process is anything but simple. In fact, it is a dynamic process that can change between business areas based on the use of codes or code data. Not everyone uses the codes in a standard way. If we’re completely honest, not everyone applies the codes according to the official coding guidelines. What we code is wholly determined by our understanding of the codes and how to apply them. The same is true for how codes are used within a payor system and how claims processing and adjudication rules are coupled with codes in the systems. Therefore, a standard “crosswalk” is not a solution based in reality in today’s healthcare environment.

But we shouldn’t feel defeated or start looking at ICD-10 implementation as some sort of insurmountable obstacle. Instead, let’s set aside our frustrations, breathe, and take a moment to assess what needs to be done to translate our ICD-9 world into the language of ICD-10. Here are some tips to get you started:

Assess and prioritize what requires modification. Because the implementation clock is ticking, don’t waste your precious time on efforts that can wait until after the implementation date has come and gone. Focus on what absolutely needs to get done in time for testing and ahead of implementation.

Take stock of your internal coding expertise. Leverage the human resources you have to help in any translation efforts you may have going on, regardless of whether they are expert coders or know “just enough to be dangerous.” Get started and assess where your gaps in knowledge are.

Identify your clinical resources. Clinical knowledge may be all you need to address any gaps that can’t be filled by your coding expertise. Sometimes it’s only a small piece of the puzzle that will yield the solution.

Take advantage of free resources – GEMs and ICD-10 manuals are available free of charge through CMS (www.cms.gov/Medicare/Coding/ICD10) along with the new Road to 10 provider portal (www.roadto10.org). Start by familiarizing yourself with the ICD-10 code set using the manual, and then you can begin any translation by looking up your ICD-9 codes in the GEMs. Use the manuals, which provide coding guidelines, to identify any codes that the GEMs do not identify. Remember, the GEMs are only an approximation.

Align your translations with your business requirements. Translation does not end with the identification of the appropriate ICD-10 codes. Review your translations in the context of your business requirements. Some ICD-10 codes may not be applicable, and there may be additional gaps that will need to be addressed.

Create a review and approval process. Employ more than one set of eyes to review the translations, ensuring that all solutions are as complete and accurate as possible. Formalize the approval process by identifying the owner of the process, and make sure he or she is responsible for approving any translation solution along with when the approval was given.

Archive your translation solutions. Who knows what will be needed in terms of documentation, post-implementation, so make sure you have all solutions and their related information archived and available for future reference.

Don’t sweat the small stuff. And don’t bite off more than can be chewed properly before October 1, 2015. But do get started sooner rather than later!

About the Author

Mandy Willis is a Certified Coding Specialist and AHIMA Approved ICD-10 Trainer with 15 years of experience in the healthcare industry. She has worked in the small physician practice environment, commercial payer and Medicare and Medicaid. Currently, her focus is on assisting all sectors of the healthcare industry in making the transition to ICD-10.

An expert panel convened by federal regulators has offered recommendations for functional status quality measures in skilled nursing facilities.Released Friday was a summary of the experts' advice to create a functional status quality measure in SNFs, as well as inpatient rehabilitation facilities and long-term care hospitals.

The panel also announced that it had decided against recommending that items from Section G of the Minimum Data Set be used to determine a restorative goal.

The Centers for Medicare & Medicaid Services contracted with nonprofit research organization RTI International to convene the experts, including rehabilitation clinicians, administrators and researchers.

The discussion centered on the use of items from the Continuity Assessment Record and Evaluation (CARE) set, which was developed as part of a demonstration project to standardize assessments across different post-acute settings. Specifically for SNFs, the experts examined four outcome measures: the change in self-care and change in mobility scores for medical rehabilitation patients, and the discharge self-care and discharge mobility scores for these patients.

Most CARE mobility and self-care items already are assessed in SNF settings, as well as in IRFs, the experts noted. However, “challenging mobility activities” such as car transfers are not routinely assessed in these settings. Assessing these abilities is important for residents who are returning home or to a community-based setting, they concluded.

The panel also addressed risk adjustment. Individuals who have an incomplete stay — including those who die or are unexpectedly transferred to a hospital — should not be included in calculating the quality measure, they recommended. Neither should those who have maximum scores on the self-care and mobility items at admission, since they have no room for improvement. Gender and Medicaid status should be excluded, but age, history of falls and prior functional status would be appropriate risk-adjustment factors, the panel determined.

Not all self-care and mobility items would be applicable in each post-acute setting, the panelists noted. For example, they discussed dropping the “wash upper body” item for SNFs, because most residents bathe in a tub or shower.

Improving patient satisfaction and enhancing the hospital experience is all the buzz today in health care. Every hospital executive across the country is talking about it, and coming to terms with how their organization’s reimbursements will be directly tied to their performance in this area.

A decade ago, none of us had ever heard of HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores, the core metric by which health care facilities are now being evaluated. And while improving patient satisfaction scores is a complex issue that requires a multifaceted approach from all levels of the organization, one thing is certain: As the most visible frontline clinicians during any medical patient’s hospitalization, hospital medicine doctors are key to driving this improvement. They are the face of the hospitalization, act as the main point of contact for the patient, and are the doctors who will be most involved in their care. The old model of the hospitalist being present “to just round” on patients in place of their regular PCP is long outdated. It’s therefore crucial to recognize their role in improving the hospital experience. Here are some everyday ways hospitalists can do this:

Making clear to the patient from the beginning the role of the hospitalist, their relationship with the patient’s PCP, and how they will be in charge of the patient’s complete care as part of a collaborative care team. This helps to reassure an often anxious elderly patient and their family.

Regular use of aids such as explanatory introductory cards, pamphlets and business cards. Leave them on the table in the room so that family members can also see them and know the doctor who’s in charge of the care.

Making a clear plan for the patient every day. Utilize whiteboards in the patient’s room and keep them updated.

Developing more optimal patient rounds, including multidisciplinary rounding models to ensure that all members of the health care team are on the same page.

Setting aside dedicated time for extended patient and family meetings each day, usually in the afternoons.

Making clear that you are regularly communicating with the specialists who are also involved in the patient’s care.

Statistics show that two of the most frequently cited patient complaints are a lack of time with their doctors and health care staff exhibiting poor communication skills. On a practical level, in order to maximize time with patients, hospitalists obviously need a manageable daily patient census. Formal communication skills training is often well received by physicians, especially if feedback is given in a friendly and collegial atmosphere. It’s traditionally been an area that the health care profession hasn’t got into, and older physicians in particular are much less likely to have ever received any formal training or skills advice.

Worried about pushback if you bring up the concept? Most physicians actually enjoy thinking about the topic, and are very keen to improve their skills. Ultimately, it’s all about making the patient feel comfortable, at ease, and listened to. Some proven communication techniques that physicians should utilize include making eye contact, sitting down, and asking open-ended questions. These are very basic, but often forgotten about during a typical hectic day. They can all be taught, improved upon, and coached.

Specialists also need to step up to the mark. They need to be encouraged to maximally collaborate with the hospital doctor and to make the patient feel like all their care is being coordinated. The other touches that go into improving a hospital stay, such as regular nursing checks, being clear on wait times, and following up post-discharge with a personal (non-automated!) message from a nurse or administrator, should all be added to the mix.

Let’s remember that this isn’t simply about saying that you’ve “improved patient satisfaction” and raising survey scores for the sake of reimbursements. Patient satisfaction is really about understanding what the patient is experiencing and the emotional roller coaster that goes with being sick. HCAHPS scores, while by no means the perfect survey, may be the jolt the medical profession needs to strive for what it should have been doing all along: providing patients with a high level of customer service at a low point in their lives.

Hospital medicine doctors are best placed to engage the patient from the beginning, and by focusing on the hospitalist group to lead the way, organizations can soar to new heights.

Sunday, March 30, 2014

We are getting ready to watch the
highly anticipated men's freestyle mountain climb.

This is the "iron man" of
the Olympics, what you have all been waiting for.

Natalie, I hate to interrupt but I
have just received breaking news in tonight's games, it appears the two
favorites:

Johnny Three-Scoops and Earl
Strong-Fit will not only be fighting for their individual victories tonight,
but the fate of their entire teams may lie in the outcome of this single event.

With only 3 events to go, and this
being the only event in which their respective teams have a real contender,
this could decide the gold Dr. D. If I am correct, TEAM UNFIT and TEAM HEALTH
are tied 9 to 9 in the medal count!

ALL EYES WILL BE ON THESE TWO TONIGHT!

YOU, can help TEAM HEALTH reach the
top first by correctly answering the questions!

ARE YOU UP FOR THE CHALLENGE?

Click the picture above to launch the game or visit us at www.mhealthgames to play!

Thursday, March 27, 2014

After a fiery debate on the House floor that nearly ended when Rep. John J. Duncan (R-TN) declared the bill had the requisite two-thirds majority to pass, Rep. Joe Pitts (R-PA) objected to the vote, saying that a quorum was not present.

That appeared to push back a bill that would have created a temporary Sustainable Growth Rate fix and delayed the ICD-10 compliance deadline.

Only, not so fast.

That was at 10:31 am. Then after quickly moving on to debate supporting the independence of Ukraine, and a short recess, at 12:09 pm the House convened and “on motion to suspend the rules and pass the bill Agreed to by voice vote,”according to the House's Office of the Clerk website.

Before ICD-10 is formally delayed and the SGR fix becomes permanent, however, the Senate has to vote on the proposed legislation and President Obama must sign it into law.

During the 40 minutes of debate prior to the House’s first verbal vote, Pitts cited a Heritage Foundation statement saying that a temporary SGR patch was better than a deficit.

“A vote now is a vote against seniors,” Pitts said. “We are not voting for the AMA today. We’re at a deadline and this is the last vote we’ll have. If you vote no, you’re voting against seniors.”

The American Medical Association surprised ICD-10 observers by circulating a statement urging House members to vote down the proposed legislation – without a mention of the code sets at all – because it wants payment stability for its constituency.

Without a fix to the Sustainable Growth Rate formula, Medicare physicians face a 24 percent reimbursement cut beginning April 1. The debated bill, H.R. 4302, introduced by Joseph Pitts (R-Pa.), proposed replacing the reimbursement cut with a 0.5 percent payment update through the end of 2014, and a zero percent payment update for the period of Jan. 1 through March 31, 2015.

Several House members spoke out against the bill, including Sandy Levin (D-MI).

Levin continued that serious discussion about how to pay for the permanent fix has been lacking and the result is a complicated bill that several Representatives said is a misstep, and one that House members have yet to even understand.

“I challenge any member to come up here and say I have read this bill,” said Rep. Steny Hoyer (D-MD). “None of us know what the substance of this bill is. We do not have the courage to rationally fund that agreement. This is a game unworthy of this institution and the American People.”

The leadership, House Speaker John Boehner (R-OH) and Senate Majority Leader Harry Reid (D–NV), bringing this bill to the floor without most people having had the chance to digest it is what Rep. Nancy Pelosi (D-CA) called a missed opportunity.

“We should be seeking a bill that would permanently fix SGR,” Pelosi said. “This band-aid is the wrong way to go. It doesn't address the underlying problem. We could have done that, we’ve been trying to for 10 years. It’s always something the Republican majority backs away from.”

By: Jonah Comstock | Mar 26, 2014
The term “disruptive innovation” has become so much of a buzz word, it’s not uncommon to hear it applied to just about any radical shift in care. But for Harvard Business School professor Clayton Christensen, who invented the term, it has a very particular meaning. Most innovations are “sustaining innovations” — they make an existing product better and cheaper for its existing customers, and allow producers to sell it at a better margin. Disruptive innovations actually drive costs down, but ultimately end up more profitable because they open up the market to customers that didn’t exist before.

At Better Health Boston, a one-day event for healthcare industry stakeholders hosted by McKesson Corporation, Christensen talked about how the idea of disruptive innovation really applies to healthcare — and what the healthcare system needs to do to go forward.

As an example of a disruptive innovation cycle, Christensen talked about the computer business, specifically the move from $2 million mainframes to $200,000 minicomputers to $2,000 personal computers, and finally to $200 smartphones. He pointed out two things: each innovation brought computing technology to a larger segment of the population, and none of the market leaders in any part of the chain was able to stay a market leader in the next part (with the possible exception of Apple).

“[Makers of minicomputers] got no signal that the personal computer mattered to their customers, because it didn’t matter to their customers,” he said. “We started using a PC for simple things and then the tech got better and better and better, until we could solve all our problems with a personal comupter and we didn’t have to buy a mainframe anymore. And the leaders in that space got killed. … It’s not that the market leaders didn’t see it coming. It’s that it made no economic sense.”

In healthcare, the market already includes all the possible consumers. The way disruptive innovation will happen, he believes, is in the form of decentralization. Rather than just innovating diminishing returns on better and better hospital-based treatment mechanisms, innovation will consist in taking equal or even inferior versions of technology that exists in hospitals and moving it outward — to clinics, retail clinics, and, eventually, the home.

The way that technology enables that shift outward in care is by doing what Christensen calls “commoditizing experience.” As the scope of medical knowledge has increased, doctors have already made a shift from intuitive care, where educated guesses and trial and error came to bear in treating patients, to evidence-based medicine, where doctors devise treatment plans based on what’s worked best historically in patients with the most similar symptoms.

The shift from evidence-based medicine to personalized medicine, where the doctor uses detailed data about a particular patient to devise a highly specific treatment plan, will be the same kind of shift. Each gradation makes diagnosis and treatment easier to teach, allowing more parts of care to scale out from physician specialists to nurse practitioners to patients and families.

Decentralization will also solve what Christensen considers a fundamental business problem for hospitals.

“In a typical hospital, overheads account for 85 to 90 percent of total costs because of the complexity of offering a ‘one size fits none’ offering,” he said. “It turns out there are three different business models inside a hospital, and those three business models are incompatible.”

The diagnostic function of a hospital functions similarly to a consulting firm, he explained, and works best with a fee for service business model. The acute care and surgery functions of a hospital are a process business, like manufacturing or education, and should have an outcomes-based business model. Finally, chronic disease management and patient community-building are facilitated networks, like telecom companies or insurance companies, and they want a membership-based payment model. Decentralization of care would enable each of those businesses to operate more efficiently, with less overhead.

Christensen thinks actual disruptive innovation in healthcare hasn’t really begun yet. But technologies on the horizon — from home health sensors, to telemedicine, to increasingly sophisticated population health management, could start to move that needle.

Wednesday, March 26, 2014

A revolutionary new way to engage and
empower all stakeholders in the healthcare learning system.

Think for a moment about Gamification and The Institute of Medicine's new
report "The Path to Continuously
Learning Health Care in America"

The Characteristics of a Continuously
Learning Health Care System...

Science and Informatics

Real-time access to knowledge—A
learning health care system continuously and reliably captures, curates, and
delivers the best available evidence to guide, support, tailor, and improve
clinical decision making and care safety and quality.

Digital capture of the care
experience— A learning health care system captures the care experience on
digital platforms for real-time generation and application of knowledge for
care improvement.

Patient-Clinician Partnerships

Engaged, empowered patients— A
learning health care system is anchored on patient needs and perspectives and
promotes the inclusion of patients, families, and other caregivers as vital
members of the continuously learning care team.

Full transparency— A learning health care system systematically monitors the safety,
quality, processes, prices, costs, and outcomes of care, and makes information
available for care improvement and informed choices and decision making by
clinicians, patients, and their families.

Continuous Learning Culture

Leadership-instilled culture of
learning— A learning health care system is stewarded by leadership committed to
a culture of teamwork, collaboration, and adaptability in support of continuous
learning as a core aim.

Supportive system competencies— A learning health care system constantly refines complex care
operations and processes through ongoing team training and skill building,
systems analysis and information development, and creation of the feedback
loops for continuous learning and system improvement.

These games represent more than
education, more than engagement – they represent an innovative way for patients
and clinicians to work together for a healthier tomorrow.

We are successfully changing the
current landscape through integrated delivery systems, higher quality care, and
advanced technology. These innovations are transforming the way we manage
populations through big data.

But once the opportunity has been
identified, do we have the tools to close the gap?

We do now -

This has been the most amazing journey
yet, and now because of your overwhelming interest and support we have a new
venture…. www.mHealthgames.com

If you are looking to add games to your current patient portal – this is
AWESOME!

Many physicians are adopting patient portals in response to governmental incentives for meaningful use (MU), but the stage 2 requirements for portal use may be particularly challenging for newer electronic health record (EHR) users. This study examines enrollment, use based on MU requirements, and satisfaction in a recently-adopting fee-for-service multispecialty system. The Centers for Medicare and Medicaid Services (CMS) financial incentives for meaningful use (MU)1 likely will persuade many reluctant doctors to adopt electronic health records (EHRs). However, there are strong concerns about whether most physicians will be able to adopt and utilize these EHRs to meet MU standards.

The study team examined data from 2010 to 2012 of users of a available patient portal linked to the EHR of a multispecialty academic group practice and 10 affiliated community primary care clinics. Patient portals linked to commercial EHRs are likely to offer the most commercially practical way for new EHR users to meet CMS MU patient access regulations. The results indicate that even some large centers with patient portals will have difficulty with some of their physicians' enrollment targets.

The study suggests that patients at later-adopting centers are moving quickly to embrace online programs, and that primary care, but not specialty physicians, can satisfy many of their expectations even without large redesigns of care.

The National Committee for Quality Assurance has released a next-generation set of standards for patient-centered medical homes, called PCMH 2014.

The accreditation organization uses the standards to assess primary care practices seeking NCQA PCMH Recognition. About 7,000 practice sites with 35,500 clinicians have received recognition and that accounts for more than 10 percent of the nation’s practices, according to NCQA.

Further, there are six must-pass elements necessary for recognition: patient-centered appointment access, components of the practice team, using data for population management, care planning and self-care support, referral tracking and follow-up, and implementing continuous quality improvement.

“To earn NCQA recognition, practices must meet rigorous standards for addressing patient needs; for example, offering access after office hours and online so patients can get care and advice where and when they need it,” according to the organization. “PCMHs get to know patients in long-term partnerships, rather than through hurried, sporadic visits. They make treatment decisions with their patients, based on patient preference. They help patients become engaged in their own healthy behaviors and healthcare.”

NCQA also continues to emphasize the importance of meaningful use of health information technology and health information exchange to support coordinated and patient-centered care, across provider sites.

According to NCQA, changes in the new standards include:

* Integrating behavioral health into a practice: Practices are expected to collaborate with behavioral health providers and communicate the benefits of such treatment to patients.

Tuesday, March 25, 2014

WEST HOLLYWOOD, Calif. (AP) - Before the car-wreck victim reached the emergency room, doctors, residents and nurses at Cedars-Sinai Medical Center knew what to expect by glancing at their smartphones.

The details came in the staccato of text messages: A 35-year-old man had driven head-on into a bus. He suffered major chest injuries. His vital signs were crashing.

This was not just another day in the hospital. It was a laboratory billed as the "OR of the future," an ongoing experiment aimed at breaking down barriers that bog down care through open communication, better use of technology and teamwork.

In reality, trauma care is rarely this organized. But those who are prized for individual skills are increasingly learning that when it comes to treating trauma patients from accidents, natural disasters or terrorist bombings, communication and coordination can determine whether someone lives or dies.

At an office building less than a mile from the main Cedars-Sinai campus, doctors are guinea pigs in simulations designed to test such skills.

There's a "mission control" room filled with video screens where trainers keep track of the action. The walls are see-through. Open workspaces are favored over cubicles.

At the heart of the lab is a room that could be outfitted as the ER, operating room or intensive care unit - depending on the practice of the day. Medical simulation labs have evolved over the years, from simple lifelike models of body parts that doctors train on to full-blown replications of hospital rooms where trainees can practice different situations. The Cedars-Sinai space strives to speed up trauma care by eliminating workflow disruptions and honing communication skills.

"Health care today is delivered more by teams rather than by individuals. We have to educate folks in teamwork skills," said William McGaghie, who heads a professional training institute at Loyola University Chicago Health Sciences Division.

Registered nurse Anna Doyle is used to working with doctors who parachute into the latest crisis, whether it's tending to the victim of a gunshot wound or rollover accident. It's often a chaotic scene, and not everyone takes the time to get to know one another.

During a recent rehearsal, a resident piped up and asked for everyone's names. For a second, it felt like the first day of school as introductions were made.

Doyle said she found the introductions calming - even if it was just practice.

"We had a personal moment ... that never happens," said Doyle, acknowledging that there's always a line of walking wounded in an emergency.

Armed with a $4 million grant from the Defense Department, doctors and nurses at Cedars-Sinai have been testing ways to improve trauma care by running simulations at the newly opened lab that oozes tech startup.

"This is a place for experimentation," surgeon-in-chief Dr. Bruce Gewertz said.

Before the lab opened, Gewertz and his colleagues followed real trauma patients from the moment they were unloaded from the ambulance to their transfer to the ICU. Along the way, the team documented obstacles that slowed down care: Too many people spoke at the same time, prompting a nurse to ask a resident to speak up. A patient went for a CT scan only to find another patient already in the scanner. A resident's cellphone rang while scrubbing in.

Most of the time, researchers found, delays in care were caused by a lack of communication and logistical hurdles.

The goal is to get everyone on the same page during the "golden hour," a concept borrowed from military medicine when time is of the essence.

The team recently partnered with a consulting firm to develop an in-house iPhone app that displays a patient's vitals and blasts out the information to the trauma team as members are assembling. There's also a text-messaging feature that allows doctors and nurses swarming in from various parts of the hospital to communicate with one another before the patient arrives.

It's too early to determine how much it would cost if the app was part of routine care, but Gewertz said it'll be relatively inexpensive, involving the cost of the phones and a monthly license fee for protected data storage.

On a recent weekday, the team's cellphones buzzed with the condition of the first "patient" of the day, the bus-crash victim.

Typically, doctors don't know vitals until a nurse scrawls them on a whiteboard.

Apps can be helpful, allowing medical teams to "know the information en route so they're not coming in cold," said Pam Jeffries, president of the Society for Simulation in Healthcare and a professor at the Johns Hopkins University School of Nursing. Jeffries is not involved in the Cedars-Sinai effort.

The patient - a high-tech dummy - was wheeled in, moaning and complaining. Doctors and nurses sprang into action, ripping off the dummy's clothes and placing a breathing tube before transferring him.

Despite the quick response, there were hiccups, mainly because of a lack of experience. Residents had trouble inserting the tube, and it took several tries to get it right.

For the second scenario, the team was not given advance information about the patient and kept going in circles asking for any details. A doctor said he heard it was a case of a pedestrian hit by a car.

"Do we know if it's male or female?" another asked.

"I don't know much more than auto versus" pedestrian, the doctor said.

The chief resident said there's worry about internal injuries and to make sure blood supply and other essentials were ready.

As if that weren't enough, they also had to deal with a fire - simulated smoke from dry ice was pumped into the room. One called out for the fire alarm to be shut off while the rest prepared to move the patient to a gurney.

In the chaos, doctors didn't realize the wheel on the gurney was locked and wasted time fiddling.

E-visit a doctor: A new service allows patients to send an electronic message to Sanford Clinic, hear back from a doctor and have a prescription sent to a pharmacy. Reporter Jon Walker interviews a Sanford official and a patient

A visit to the doctor now comes without the visit.

Sanford Health has begun offering an electronic option in clinical care. A patient with a health problem can sit at a computer, type a summary of symptoms, attach a credit card number and hit the send key. A response from a Sanford provider with a prescription or medical advice comes back in four hours or less. It costs the patient $55.

The format depends on a patient’s skills in self-diagnosis and the medical system’s ability to respond without any conversation or face-to-face interaction, but it’s mostly a bow to consumer convenience in the computer age.

“It’s so a patient can receive information they can trust as opposed to just Googling,” said Louise Papka, a physician assistant in acute care for Sanford.

Michele Kleinwolterink, 44, said it helped her. She could feel a sinus headache developing two weeks ago as she drove to her job as executive assistant at Bluestem, a private equity company in downtown Sioux Falls.

“I knew I needed to go to the doctor but it was a busy day,” she said. “Sinus headaches don’t just go away. You need meds as soon as possible.”

From her desk, she logged on to her account at My Sanford Chart, the health system’s online records platform. A prompt directed her to an e-visit page, where she answered questions and described her condition in a box allowing a narrative up to 250 characters.

“You answer the same questions you would in the doctor’s office and tell them about your pain,” she said.

It took her 10 minutes. She filed her request and waited.

Sanford pledges a response within four hours but says the average is half that time. It was shorter for Kleinwolterink.

“It only took 10 minutes ... to get an email back from a doctor and they said, ‘You have a prescription waiting for you at your pharmacy that you selected,’” she said.

Sanford has been doing a trial run with the program and last week began offering it to all patients in South Dakota, Iowa and Minnesota. It hopes to add North Dakota this summer. Patients filing an e-visit likely are not communicating with their own doctor but with someone in Sioux Falls who is either a physician or an advanced practice provider such as a physician assistant or nurse practitioner. Sanford has been receiving 20 to 30 requests a week.

7 nonemergency conditions covered

It’s only for adults, only for patients enrolled in the My Chart program and only for seven conditions that are not emergencies. The seven are sinus headache, pink eye, urinary tract infection, vaginal discharge, diarrhea, cough and back pain.

Helping patients control their health

Self-diagnosis plays to a Sanford goal of having patients take ownership of their own welfare, which is one pillar of the national health reform movement. Patients still will visit clinics to see doctors, and they still can call for what still is free advice over the telephone. The e-visit is an option for those with relatively minor problems, who prefer texting and don’t want to sit in a waiting room.

“A lot of problems, a patient is looking for confirmation,” said Dr. Dan Heinemann, chief medical officer at Sanford Clinic. “They don’t have anything serious that they can’t continue to manage at home. ... If I have chest pain, this is not going to do it. But if I have a cough, it’s relatively easy.”

Medicare doesn’t cover an e-visit, but some insurers do. Kleinwolterink said she paid $25 of the $55 fee with a credit card and that Blue Cross Blue Shield covered the rest.

The health charts are a secured format requiring membership and a password entry to ensure privacy. Identity fraud is always a concern in health care, with the intent usually to misuse insurance. The e-visit, though remote, is reliable communication, said Terri Carlson, vice president at Sanford Clinic.

“Our risk folks prefer this over telephone calls. We have objective data in the questions patients have answered,” Carlson said.

Sometimes intimate details in writing

Still, the e-visit marks a cultural shift for patients to commit to writing private details about their health in order to communicate with a website. Some of the seven conditions, such as sinus headaches and back pain, are generic problems, while the others are more intimate.

“It’s a sign of the times to be using technology ... to be making that connection between the consumer and the health care market,” said Lorna Saboe-Wounded Head, assistant professor of consumer affairs at South Dakota State University. “With the social networks, maybe people are more willing to explain the problems they have, even if it’s very personal.”

Safeguards for prescriptions

Randy Jones, executive director of the South Dakota Board of Pharmacy, said health providers are allowed to prescribe drugs by electronic format without seeing a patient. It should be an established patient-doctor relationship that includes safeguards to prevent prescriptions that are improper or premature, he said.

“If they say I’ve got this hacking cough, do they know if it’s viral or bacterial without a lab exam? The answer is no. I would have some concerns,” Jones said. “If the prescriber has valid concerns, they should require that patient to come in for a physical exam and potential lab tests.”

Sanford says it has those safeguards in place. Under those circumstances, “it can be done with care,” Jones said.

Heinemann said the questions a patient must answer serve as a filter.

“If a patient says in an e-visit, ‘I’m really short of breath, I have pain when I breathe,’ those are red flags and probably the individual needs to get in to see a doctor,” Heinemann said. “Most of the time ... I think we can do a pretty good job without seeing the patient.”

Sunday, March 23, 2014

Boxed in by rivals in video games, Nintendo outlined its plan to redefine itself as a health-oriented entertainment company in the coming decade. In a letter to shareholders, Nintendo chief executive Satoru Iwata said the company plans to expand beyond games to make entertainment that improves “quality of life” for people.

Iwata talked about Nintendo’s history since its founding as a seller of Hanafuda, or traditional Japanese playing cards, 125 years ago. It innovated and shifted to becoming a toy company, then an electronic toy company, and then a video game company. Nintendo launched its first game console, the Nintendo Entertainment System, in 1983. Its Wii console in 2006 was a big success, but the Wii U has been a disaster, and the 3DS handheld isn’t selling as many as its predecessor, the DS.

So to adapt to the shifting market, Nintendo is expanding into health.

Above: The Nintendo Vitality Sensor.

Image Credit: Nintendo

“As the business environment around us has shifted with the times, we have decided to redefine entertainment as something that improves people’s quality of life (“QOL”) in enjoyable ways and expand our business areas. What Nintendo will try to achieve in the next 10 years is a platform business that improves people’s QOL in enjoyable ways,” Iwata said.

Back in 2009, Nintendo hinted at a health entertainment strategy when it announced a “vitality sensor” that could measure your heartbeat and input that data into a Nintendo Wii game. But Nintendo never shipped that sensor.

Health tech is a rising, competitive field in the U.S. But to compete in it, Nintendo not only has to deal with competitors with more knowledge and more experience in the sector, but it may also need to learn how to work with the U.S. Food and Drug Administration. (Ask 23andMe how that went.)

He said that Nintendo will still remain focused on dedicated video game hardware and software platforms.

But he added, “We will attempt to establish a new business area apart from our dedicated video game business. We have set ‘health’ as the theme for our first step and we will try to use our strength as an entertainment company to create unique approaches that expand this business.”

Nintendo wants to expand its base of users, much like it did with the Wii, whose motion-sensing controller was so easy to use that it appealed to people who weren’t traditional video game fans. With its new health products and services, Iwata said that Nintendo wants to “create an environment in which more people are conscious about their health and in turn expand Nintendo’s overall user base.”

“What has remained the same from the past is that we have always tried to create something new from materials and technologies available at that time, to position entertainment as our core business and to improve people’s QOL in enjoyable ways,” Iwata said. “We will continue to value self-innovation in line with the times and aim for growth.”